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Dispatches From Ethiopia — A Firsthand Look on the State of Neurology Training

ADDIS ABABA, ETHIOPIA—More than 2,000 years old, Ethiopia is one of the most ancient civilizations in the world. Yet it continues to struggle to provide its people with basic resources, and medicine is no exception. In this country of 80-million plus people, there is a shortage of physicians — only 15 neurologists serve the entire country and most are concentrated here in the capital city — making it difficult for all who need care to see a neurologist.

This is particularly dire because neurological problems — including neuroinfectious and non-infectious diseases — are on the rise.

But what the country lacks in resources, the people attempt to make up for with their generally positive and hopeful spirit. The country is currently undergoing a health care system reformation, and eradicating the spread of HIV/AIDS, malaria, and persistent neuroinfectious diseases are top priorities.

A NEW RESIDENCY PROGRAM

Neurology is at the center of those efforts. “Ethiopia has taken a fabulous first step in addressing its own needs,” by establishing the first and only residency program in neurology at Addis Ababa University Faculty of Medicine Black Lion Hospital in 2006, said James H. Bower, MD, associate professor of neurology at Mayo Clinic in Rochester, MN.

With one neurology residency in place, the goal is to have neurologists on staff at all eight medical schools, Dr. Bower said.

Dr. Bower, who studies the prevalence of neurologic disease in Ethiopian hospitals, has been going to Ethiopia annually since 2001 to teach the internal medicine residents in Addis Ababa about neurology and movement disorders (his specialty). Now he teaches at two more of the other medical schools in the country, at Gondar and Jimma, and has inspired other colleagues from Mayo to teach, as well.

“Because of our frequent trips to Ethiopia,” he said, “I met Enawgaw Mehari [of People to People], and we chose to combine our efforts to improve the services there.”

Dr. Mehari's group; Dr. Bower and other Mayo staff; and Guta Zenebe, MD, a neurologist at Black Lion hospital, and other staff neurologists there helped create the neurology residency. The Ethiopian neurologists and People to People physicians from multiple specialties — many of whom now live and practice abroad — reviewed the curriculum and donated their time, finances, textbooks, and expertise.

Before the neurology residency program was established in 2006, Ethiopians had to go abroad to study neurology, and not all returned to practice in Ethiopia.

Today, Ethiopian medical school graduates work for two years (as a medical school lecturer or at a clinic or hospital); then train in internal medicine for three years; and train for two additional years in neurology. Neurology is treated as a specialty within internal medicine.

“Currently, internists and pediatricians treat all the neurological cases in the big hospitals,” said Shitaye Alemu, MD, an internist from the University of Gondar. “In the district hospitals, general practitioners treat them.”

There are approximately 1,000 general practitioners, or freshly graduated doctors, and 100 internists in Ethiopia.

But the neurology residency program has clearly made a dent in the pipeline, doubling the number of neurologists since 2006. “They will never reach Western proportions in the near term, but at least they have started training the specialists that are needed to train the internists and general practitioners in caring for those with neurologic diseases,” said Dr. Bower.

FIRST WOMAN NEUROLOGIST

One of the graduates of the residency program's first class made history — not only as the chief resident of her class, but also as the first woman neurologist in the history of Ethiopia.

Dr. Zebenigus works at Addis Ababa's Yehuleshet Higher Clinic, a private clinic. On the day this reporter visited, the clinic, staffed with three physicians and several nurses, had a waiting room packed with patients — a typical situation, Dr. Zebenigus said, because hospitals are overloaded and the health care is generally better at private clinics (where patients pay more for care than in government facilities). Since there is no insurance system here, everyone pays out of pocket, which means that the richer patients can afford private care but the indigent must use government hospitals. However, some corporations will pay for health care out of the employee's salary.

Yet another reason for Yehuleshet's popularity is that it houses two of the few working EMG machines in the entire country. Steven Brown, neurology coordinator at Pleasant Valley Hospital in Point Pleasant, West Virginia, and director of neurology training for People to People, had recently sent the second machine to Yehuleshet, and was setting it up in the clinic the day this reporter visited.

Support from individuals and networks like People to People overseas is critical, said Sisay Gizaw G. Michael, MD, a chief resident at the Addis Ababa Faculty of Medicine, who is in the final year of his clinical neurology residency. He noted that the residency program needs neurodiagnostic tools and equipment — EMG and EEG machines, for example — reference materials and textbooks, technical support to refine its curricula and expand training to other schools in the country, and physicians with expertise in specialties like neuropathology, neuro-electrodiagnosis, and neuro-oncology to improve the quality of education through rotation short-term visits.

“Practical learning is very important and people with experience can share what they know by coming here or our residents going elsewhere,” Dr. Zebenigus said.

“We also need devoted professors like Dr. Zenebe to help the residency program grow,” Dr. Zebenigus said. Training more doctors is imperative; because about 50 percent leave the country to practice, Ethiopia must offer something appealing to retain them, she said.

“It is because we are poor that our doctors are going to look for better pay and life outside Ethiopia,” said Dr. Alemu. “When physicians come back to the country after their experiences in developed nations, where the resources and conditions are better, they find it difficult to adjust.”

HEALTH CARE REFORM

The residency program needs the local government's help in powering ahead, as well, said Dr. Zebenigus. And neurology in the country should get a boost as the entire health care system is reformed.

The Ethiopian government is currently attempting to decentralize the health system and improve the functioning of hospitals by granting them more responsibility and accountability. Currently, hospitals have little decision-making power, as most budgetary and hiring decisions are made through the Ministry of Health. Hospitals eventually will be run by CEOs with a board to oversee local performance, and the new policies are now being implemented and CEOs are being trained.

At a panel discussion on May 8 at Arat Kilo Science Faculty in Addis Ababa, the Minister of Health, Tedros Adhanom, PhD, told the audience of physicians that the government is making progress in completing the more than 2,500 new health centers it had committed to build by 2010.

As of December 2008, 11,446 health posts (including small clinics and hospitals) had been created to bring primary health care services to all communities. Dr. Adhanom explained that the goal of sending two health care workers to each village in the country — 30,190 health workers total — had been reached by December 2008, and this had already improved the provision of services. “The results have been greatly encouraging,” he said.

Medhin Zewdu, MD, chief of staff at the Ministry of Health, remarked that, among other goals, the health system aims to improve its ability to obtain and distribute pharmaceutical supplies and other medical resources, reverse the slow hiring process, and remedy the shortage and high turnover of staff. She also pointed out that increased urbanization in the country and an increase in the number of hospitals and medical centers mean that more neurology specialists will be needed.

A task force team, with members from People to People, the Addis Ababa University Medical Faculty, and the Ministry of Health, has been established to improve communication and collaboration on a common goal: enhancing general medical care in Ethiopia. For more information on People to People and to support its mission, visit www.peopletopeople.com.

Several months after Neurology Today published a profile about Enawgaw Mehari, MD, a Morehead, KY, neurologist and native of Ethiopia who founded People to People, a nonprofit organization in 1999 to combat HIV/AIDS in Africa, this reporter was invited to accompany a delegation of neurologists and other physicians to Ethiopia to observe and report back on the unique challenges of neurology in that country. This article is the first in a series of reports from visits to clinics, schools, and hospitals in the capital city of Addis Ababa. For more about People to People, visit www.neurotodayonline.com for “Enawgaw Mehari, MD, Founder of People to People, Tackles the Spread of HIV/AIDS in Africa,” Nov. 6, 2008.

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